Metastatic Bladder Cancer Presenting with Persistent Hematuria in Young Man with Cystic Fibrosis

We report a case of metastatic bladder cancer developing in a young man with cystic fibrosis (CF) that was initially diagnosed as ureterolithiasis and managed as renal colic. With the improved survival of patients with CF, an increasing burden of extrapulmonary disease manifestations is apparent. Renal colic is observed at an increased frequency in patients with CF relative to the general population and is a commonly recognized cause of hematuria. However, CF patients harboring a malignancy are recognized to be at increased risk of delayed identification owing to atypical symptoms and lack of demographic risk factors. This case illustrates how investigations to rule out malignancy are warranted in those CF patients not responding to therapies directed towards presumptive diagnoses. 1. Introduction Innovations in screening, pharmacotherapy, and management have reduced the morbidity and mortality of patients with cystic fibrosis (CF). From 1985 to 2010, the proportion of individuals with CF achieving adulthood (>18 years of age) increased from 29.9% to 57.2%, and median survival age increased from 36 years in 2000 to 48.1 years in 2010 [1]. With improvements in survival, increasing age-related CF complications such as malignancy must be followed [2]. 2. Case Presentation This 29-year-old male was diagnosed with CF (F508del/F508del) at two months of age. His CF is notable for pancreatic insufficiency, moderate airways disease with chronic Pseudomonas aeruginosa infection, severe CF related liver disease, and diabetes. His medical regimen included twice daily physiotherapy with a flutter, and he was maintained on Creon, ADEKs, vitamin D, Ventolin, Flovent Diskus, Pulmozyme, tobramycin inhalation solution (TOBI), Urso falk, Colace, and Nasacort. He presented with asymptomatic hematuria, at which time a CT scan demonstrated a calculus that was treated with a ureteric stent. Diagnostic cystoscopy was unremarkable. Hematuria persisted, requiring an admission two months later with a presumptive diagnosis of prostatitis. Repeated cystoscopies failed to identify new pathology. After an initial improvement in symptoms, five months after initial presentation he developed new scrotal/anal pain. Finally, a fifth cystoscopy was undertaken and revealed a mass overlying the right ureteric orifice and prostate. A transurethral resection was performed and pathologic assessment revealed an invasive high-grade urothelial carcinoma. Immunohistochemical staining was positive for vimentin and cytokeratin 5/6 and negative for PSA and neuroendocrine markers. A staging CT scan